Medical Ethics, Law and Professionalism: Capacity Governs Everything
Ethics, law and professionalism items test whether you can identify the decision-maker, the legal duty and the least intrusive justified action. Most vignettes hinge on one question: does this patient have decision-making capacity for this specific decision? Once that is answered, the rest of the management usually follows.
Core rules
- Informed consent. Valid consent requires capacity, adequate disclosure of material risks and alternatives, voluntariness, and documentation. In a life-threatening emergency with no available surrogate, treat under the emergency exception.
- Capacity. Assess four abilities: understanding the information, appreciating its application to oneself, reasoning about options, and communicating a choice. Capacity is decision-specific and is not synonymous with refusing advice.
- Confidentiality. Disclosure without consent is justified for statutory reporting, imminent serious harm to an identifiable person, court order, and suspected child or elder abuse. Otherwise share only the minimum necessary information.
- End of life. Advance directives and valid refusal of treatment are binding; withdrawing and withholding treatment are ethically equivalent; intended symptom relief that foreseeably shortens life can be justified by double effect.
- Research and professionalism. Ethics approval, valid consent, and special protection for vulnerable participants are required; declare conflicts of interest and disclose harmful errors to patients.
Worked example
A 68-year-old man with a gangrenous foot refuses amputation. He understands that without surgery he will probably die, explains that he values remaining at home over length of life, and has consistently refused over several conversations. There is no evidence of delirium or depression. Assess and document the four capacity abilities; if they are intact, respect the refusal, offer a second opinion, palliative care and vascular review, and continue non-operative treatment. Family members cannot consent on behalf of a capacitated adult. If delirium or depression is present, treat it and reassess; if capacity is lost later and no surrogate exists, act in the patient's best interests, with legal advice for major interventions.
Traps that cost marks
- Equating refusal of recommended treatment with incapacity.
- Letting a relative consent for a capacitised adult patient.
- Disclosing information to family without the patient's permission.
- Assuming age or a psychiatric diagnosis automatically removes capacity.